Interrater reliability of the Patient Education Materials Assessment Tool (PEMAT)

Objective

To assess the interrater reliability (IRR) and usability of the Patient Education Materials Assessment Tool (PEMAT) and the relationship between PEMAT scores and readability levels.

Health care provider attitudes toward patients with acute vaso-occlusive crisis due to sickle cell disease: Development of a scale

Objective

Patients with sickle cell disease (SCD) often perceive negative provider attitudes, which may affect the quality of patient–provider communication and care during vaso-occlusive crises (VOCs). This study investigated the validity and reliability of a scale to measure provider attitudes toward patients with acute VOC.

Methods

Using a cohort of adults with VOC (September 2006 to June 2007), we administered a 10-item provider questionnaire within 72 h of patient encounters. After factor analysis, we created a 7-item Positive Provider Attitudes toward Sickle Cell Patients Scale (PASS); higher scores indicate more positive attitudes. We assessed internal consistency and evidence of construct validity, exploring bivariate relationships between provider or patient characteristics and the PASS score using multilevel modeling.

Results

We collected 121 surveys from 84 health care providers for 47 patients. Patients averaged 30.3 years in age, and 60% were women. Among providers, 79% were nurses, and 70% worked in inpatient settings. PASS scores averaged 24.1 (S.D. 6.7), ranged 7–35, and had high internal consistency (Cronbach's alpha = 0.91). As hypothesized, inpatient vs. emergency department providers (Δ = 4.65, p < 0.001) and nurses vs. other providers (Δ = 0.95, p < 0.001) had higher PASS scores. Higher patient educational attainment (Δ per year = 2.74, p < 0.001) and employment (Δ = 5.62, p = 0.001) were associated with higher PASS scores. More frequent hospitalizations (Δ per episode = −0.52, p < 0.001) and prior disputes with staff (Δ = −7.53, p = 0.002) were associated with lower PASS scores.

Conclusion

Our findings provide preliminary evidence for the reliability and construct validity of the PASS score in measuring provider attitudes toward patients with VOC.

Practice implications

Future studies should examine the validity of PASS in other cohorts of patients with SCD and their providers. With further evidence, PASS may prove useful for investigating the impact of provider attitudes on the quality of communication and care provided to these patients.     

The German version of the Four Habits Coding Scheme – Association between physicians’ communication and shared decision making skills in the medical encounter

Objective

To translate a measure of physicians’ communication skills, the Four Habits Coding Scheme (4HCS), into German, to examine its psychometric properties, and to analyze its association with the OPTION Scale, which assesses physicians’ shared decision making (SDM) behavior.

Methods

We performed a secondary data analysis of 67 audio-recorded medical consultations. Reliability, internal consistency, and factorial validity of the translated 4HCS were analyzed. The association with the OPTION Scale was examined using correlation and linear regression.

Results

Testing of reliability revealed intraclass correlation coefficients above .70. Results regarding internal consistency and factorial validity were inconclusive. The correlations between the OPTION score and the four dimensions of the 4HCS were .04 (p = .782), −.14 (p = .303), −.15 (p = .279) and .55 (p < .001), respectively. In multiple regression the four dimensions of the 4HCS explained substantial amount of variation in the OPTION scores (R² = .42, P < .001).

Conclusion

The measure showed good observer reliability, however further testing is necessary. Due to the strong interrelation of both measures, SDM should be seen in the context of broader communication skills.

Practice implications

The 4HCS can be used in research and medical education. Further studies are necessary that investigate SDM within the context of communication skills.     

Validation of the Dutch functional,communicative and critical health literacy scales

Objective

While most existing health literacy (HL) measures focus primarily on reading comprehension, the functional, communicative and critical HL scales from Ishikawa et al. [19] aim to measure a broader HL spectrum. The objective of this study was to evaluate the validity of the Dutch translation of this instrument.

Methods

Two survey studies (n = 79 and n = 209) and one cognitive interview study (n = 18) were performed among samples of breast cancer patients and patients with rheumatic diseases.

Results

Analyses showed the scales measured three distinct factors and convergent validity was satisfactory for communicative and critical HL. Nevertheless, the comprehension of the items and the suitability of the response options raised some problems.

Conclusion

The HL scales seem promising to measure a broad definition of HL. By revising some of the items and response options as proposed in this article, the scale will become more understandable for people with low HL skills, which might increase the content validity and the distributional properties of the scale.

Practice implications

The scale should be revised and revalidated. An improved version should be used in practice to gain insight into HL levels of patients. This will help to develop suitable education programs for people with low HL skills.     

International application of health literacy measures: Adaptation and validation of the newest vital sign in The Netherlands

Objective

The newest vital sign assesses individual reading and numeracy skills. The aim of this study was to create a Dutch version (NVS-D) and to assess its feasibility, reliability, and validity in The Netherlands.

Methods

We performed a qualitative study among experts (n = 27) and patients (n = 30) to develop the NVS-D and to assess its feasibility. For validation, we conducted a quantitative survey (n = 329). Reliability was assessed by Cronbach's alpha. Construct validity was examined by analyzing association patterns. Receiver operating characteristic (ROC) curves determined optimal cut-off scores.

Results

Cronbach's alpha was 0.76. In accordance with a priori hypotheses we found strong associations between NVS-D, general vocabulary, prose literacy and objective health literacy, and weaker associations between NVS-D and subjective health literacy. A score of ≥4 out of 6 best distinguished individuals with adequate versus inadequate health literacy.

Conclusion

The results suggest that the NVS-D is a reliable and valid tool that allows international comparable health literacy research in The Netherlands.

Practice implications

The NVS-D can be applied in research on the role of health literacy in health and health care, and the development of interventions. The methods can be applied in cross-cultural adaptation of health literacy measures in other countries.     

Effect of cognitive dysfunction on the relationship between age and health literacy

Objective

Age is generally an inverse predictor of health literacy. However, the role of cognitive dysfunction among older adults in this relationship is not understood.

Methods

We conducted a cross-sectional survey of 446 adult patients in a large urban academic level one trauma center, assessing health literacy and cognitive dysfunction.

Results

Removing older patients (60 years of age and older) who screened positive for cognitive dysfunction attenuated the relationship between age and health literacy (r = −0.16, p = 0.001 vs. r = −0.35, p < 0.0001). Older patients screening positive for cognitive dysfunction had significantly lower health literacy than older patients screening negative and patients less than 60 years; health literacy scores did not generally differ significantly between the latter groups.

Conclusion

Much of the relationship between age and health literacy was driven by cognitive dysfunction among a subset of older adults.

Practice implications

Our findings suggest that older patients with cognitive dysfunction have the greatest need for health literacy interventions.     

A comparison of health-related quality of life (HRQOL) after natural and surgical menopause

Objective

To compare the health-related quality of life (HRQOL) of women at surgical menopause with that of women at natural menopause, utilizing the Menopause Rating Scale (MRS-II).

Study design

An institution-based cross-sectional study design was used, with 32 participants in each of two groups: women who had undergone surgical menopause of 9–12 months previously; and women who were more than 40 years of age and had had oligomenorrhoea for at least 1 year. The MRS-II was used to assess HRQOL. None of the women had received any hormonal therapy before assessment.

Main outcome measures

Total MRS-II scores along with the scores on the somato-vegetative, psychological and urogenital sub-scales were compared between the two groups.

Results

HRQOL was rated as worse by the surgical menopause group than by the natural menopause group: the total MRS-II scores were much higher for the surgical menopause group (mean = 29.4, SD = 6.7) than for natural menopause group (mean = 20.7, SD = 6.5), and this difference was significant (p < 0.0001). Similar results were obtained on the three sub-scales—somato-vegetative (p = 0.030), psychological (p < 0.0001) and urogenital (p < 0.0001).

Conclusion

HRQOL is worse after surgical than in natural menopause. Routine surgical castration at hysterectomy should be avoided because of adverse short-term effects and, potentially, long-term consequences.     

What parents want from emails with their pediatrician: Implications for teaching communication skills

Objective

Physician–patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents’ perspectives on physician–parent email communication and compared parent and faculty assessments of medical students’ emails.

Methods

This mixed methods study explored physician–parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students’ email responses were calculated using univariate general linear modeling.

Results

Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44) = .407, P < .01), but parents gave students lower scores on “acknowledges validity/expresses empathy” (P = .01) and higher scores on “provides next steps” (P < .01) and “identifies issues” (P < .01).

Conclusion

Parents place value on students’ abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same.

Practice implications

Differences between parental and faculty assessments of medical students’ emails supports the need for the involvement of patients and families in email communication curriculum development.     

Patients’ trust in their physician—Psychometric properties of the Dutch version of the “Wake Forest Physician Trust Scale”

Objective

Aim was to investigate the psychometric properties of a Dutch version of the “Wake Forest Physician Trust Scale”, which intends to measure patients’ trust in their physician.

Methods

A random sample of internal medicine patients visiting the outpatient clinic completed the questionnaire (N = 201). Dimensionality, reliability and validity of the instrument were examined.

Results

The structure of the questionnaire was best explained by a unidimensional construct. Reliability was confirmed: internal consistency was high (α = .88), and mean item-total correlations were all above .40. Construct validity was indicated by patients’ trust in their physician correlating significantly and as hypothesized with (1) satisfaction with their physician (r = .64), (2) with the length of the patient–physician relationship (r = .28), (3) with their willingness to recommend their physician (r = .71) and (4) their unwillingness to switch their physician (r = .61).

Conclusion

The results suggest the Dutch version of the Wake Forest Physician Trust Scale to be a psychometrically sound instrument to assess patients’ interpersonal trust.

Practice implications

Trust is a key feature of the patient–physician relationship, yet has been scarcely researched in other than Anglophone cultures. An adequate Dutch trust questionnaire forms the first step to gaining more knowledge about patient–physician trust in another culture and health care setting.     

Existing instruments for assessing physician communication skills: Are they valid in a computerized setting?

Objectives

This study aims to highlight the differences in physicians’ scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it.

Methods

We use the Wilcoxon Signed Ranks Test to compare physicians’ scores on each of the tools during 16 simulated medical encounters that were rated by two different raters.

Results

Results show a significant difference between physicians’ scores on each tool (z = −3.519, p < 0.05 for the first rater, and z = −3.521, p < 0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower.

Conclusion

These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results.

Practice implications

We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.     

Patient communication competence: Development of a German questionnaire and correlates of competent patient behavior

Objective

The aim of our study was to design and psychometrically test a patient questionnaire to capture patient communication competence in the context of patient–provider interaction (CoCo questionnaire). We also aimed to determine patient characteristics associated with competent patient behavior.

Methods

To assure content validity, we initially conducted 17 focus groups (n = 97) made up of patients and providers. In the main study n = 1.264 patients with chronic back pain, chronic-ischemic heart disease or breast cancer who underwent inpatient rehabilitation were surveyed at the end of rehabilitation.

Results

The CoCo questionnaire contains four scales (patient adherence in communication, critical and participative communication, communication about personal circumstances, active disease-related communication) and 28 items addressing competent patient behavior. We provide evidence of unidimensionality, local independence, reliability, a Rasch-Model fit, the absence of differential item functioning, and signs of construct validity. The most important correlates of communication competence are health literacy and communication self-efficacy.

Conclusion

The CoCo questionnaire has good psychometric properties in German. Future research should examine CoCo's responsiveness and analyze criterion validity by means of observation data.

Practice implications

The CoCo questionnaire can be recommended for use in evaluating patient communication training programs.     

Communication matters: The impact of communication and participation in decision making on breast cancer patients’ depression and quality of life

Objective

This study explored the impact of breast cancer patients’ experiences of physician–patient communication and participation in decision making on patient depression and quality of life three and six months after primary treatment.

Methods

Participants were 135 German breast cancer patients, recruited within a week after the beginning of treatment. Women were asked to complete a self-administered questionnaire at baseline and three and six months later.

Results

Patients who rated their level of information at baseline as high were less depressed after three (p = .010) and six months (p < .001) and experienced higher quality of life after three (p < .001) and six months (p = .049). Patients who participated as much as they had wanted were more satisfied with the decision making process (p < .001) and had lower depression scores three months later (p = .005). The level of participation itself (passive, collaborative, active) and the treatment type had no impact.

Conclusion

The findings reveal the significance of physician–patient communication and stress the meaning of baseline depression for later adjustment.

Practice implications

A high level of information and tailoring the involvement in decision making to patients’ desired level can help patients to better cope with their illness. Physicians should assess and treat depression early in cancer treatment.     

Patient knowledge and recall of health information following exposure to “facts and myths” message format variations

Objective

To assess if exposure to varying “facts and myths” message formats affected participant knowledge and recall accuracy of information related to influenza vaccination.

Methods

Consenting patients (N = 125) were randomized to receive one of four influenza related messages (Facts Only; Facts and Myths; Facts, Myths, and Refutations; or CDC Control), mailed one week prior to a scheduled physician visit. Knowledge was measured using 15 true/false items at pretest and posttest; recall accuracy was assessed using eight items at posttest.

Results

All participants’ knowledge scores increased significantly (p < 0.05); those exposed to the CDC Control message had a higher posttest knowledge score (adjusted mean = 11.18) than those in the Facts Only condition (adjusted mean 9.61, p = <0.02). Participants accurately recalled a mean of 4.49 statements (SD = 1.98). ANOVA demonstrated significant differences in recall accuracy by condition [F(3, 83) = 7.74, p < .001, η² = 0.22].

Conclusion

Messages that include facts, myths, and evidence to counteract myths appear to be effective in increasing participants’ knowledge. We found no evidence that presenting both facts and myths is counterproductive to recall accuracy.

Practice implications

Use of messages containing facts and myths may engage the reader and lead to knowledge gain. Recall accuracy is not assured by merely presenting factual information.     

Mastery and perceived autonomy support are correlates of Dutch diabetes patients’ self-management and quality of life

Objective

The aim of this study was to assess the associations between type 2 diabetes patients’ mastery and perceived autonomy support and their self-management skills and health-related quality of life (HRQOL).

Methods

A cross-sectional questionnaire survey was conducted among 3352 patients with type 2 diabetes. Key variables were assessed with validated questionnaires.

Results

Patients’ mastery and perceived autonomy support correlated positively with their self-management skills (r = 0.34, p < 0.001; r = 0.37, p < 0.001) and HRQOL (r = 0.37, p < 0.001; r = 0.15, p < 0.001). In the linear regression analysis, mastery and perceived autonomy support were positive correlates of self-management (β = 0.23; p < 0.001; β = 0.25; p < 0.001). Patients with more physical or psychological complications had significantly lower scores on mastery, perceived autonomy support, self-management and HRQOL.

Conclusion

Our results indicate the importance of mastery in relation to diabetes patients’ perceived autonomy support, self-management skills and HRQOL.

Practice implications

Since a greater sense of mastery is likely to increase patients’ autonomous motivation to cope with their disease, interventions can aim to influence patients’ motivational regulation. In addition, we confirmed the need for autonomy support to improve patients’ self-management skills. Professionals can be trained to be autonomy-supportive, which relates to person-centered approaches such as motivational interviewing (MI).     

Self-regulation and weight reduction in patients with type 2 diabetes: A pilot intervention study

Objective

To evaluate the efficacy of a self-regulation (SR) weight reduction intervention on weight, body mass index (BMI), glycosylated hemoglobin (HbA1c) (primary outcomes), exercise, nutrition and quality of life (secondary outcomes).

Methods

A pilot intervention (n = 53) based on SR-principles consisted of a motivational interview, group sessions and a workbook and was evaluated against standard care with (n = 38) and without a self-help manual (n = 38). Subjects were overweight (BMI > 27) patients with type 2 diabetes (52% female) from a Dutch hospital (mean age 58.14, S.D. = 8.86).

Results

No differences in the outcomes were found between the intervention and control groups at 3 (T2) or 6 (T3) months. However, results at T2 and T3 revealed that patients with higher SR-skills scores had lower HbA1c levels than patients with lower scores.

Conclusion

The SR-intervention did not significantly influence the outcomes. This apparent lack of effect might, however, partly be due to high attrition rates in all treatment groups. SR-skills were positively related to changes in HbA1c-levels.

Practice implications

Improving SR-skills of overweight diabetes type 2 patients may improve their glycemic control. Patients who are ‘external regulators’ may however profit more from directive than from SR-interventions.     

Can interactive skills-based seminars with standardized patients enhance clinicians’ prevention skills? Measuring the impact of a CME program

Objective

Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction.

Methods

Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests.

Results

OSCE scores (n = 15) revealed significant improvements in communication skills overall (p = 0.004) and within specific domains (data gathering: p = 0.003; rapport building: p = 0.01; patient education: p = 0.02), but no change in case-specific knowledge (p = 0.1). Participants (n = 14) reported high satisfaction with program methods (mean = 4.6/5) and content (mean = 4.7/5), 70% planning to alter their clinical practice. Chart audits (pre = 96, post = 103) showed increased screening for smoking (RR 1.65, p = 0.03), depressed mood (RR 1.40, p = 0.04), anhedonia (RR 1.47, p = 0.01), sexual activity (RR 1.73, p = 0.002) and drinking (RR 1.77, p = 0.04). Sampling of satisfaction among participants’ patients (pre n = 689, post n = 383) detected no increase in already high baseline satisfaction.

Conclusion

This curriculum improved clinicians’ relevant skills and screening behavior.

Practice implications

Skills-oriented CME can improve clinicians’ communication skills and screening and counseling practices.     

Duloxetine for major depressive disorder and daytime and nighttime hot flashes associated with the menopausal transition

Background

We sought to obtain preliminary data regarding the efficacy of duloxetine for major depressive disorder (MDD) during the menopausal transition. The secondary outcomes were vasomotor symptoms (VMS, or hot flashes), specifically assessed as daytime or nighttime, and anxiety.

Methods

After a single-blind placebo lead-in, peri- and postmenopausal women with MDD (n = 19) received eight weeks of open-label treatment with duloxetine (60 mg/day). The Hamilton Rating Scale for Depression (17-item) (HAM-D) was the primary outcome measure. Hot flashes were monitored prospectively using daily diaries, the Greene Climacteric Scale (GCS), and the Hot Flash-Related Daily Interference Scale (HFRDIS). Anxiety was measured with the Generalized Anxiety Disorder scale (GAD-7).

Results

Of 19 participants treated with duloxetine, 16 (84.2%) were evaluable (returned for ≥1 follow up), and 13 (68.4%) completed the study. Three discontinued due to side effects. The pre-treatment and final median HAM-D scores were 15 (interquartile range [IQR] 14–18), and 6.5 (IQR 4–11.5), respectively, reflecting a significant decrease (p = .0006). The response and remission rates were 56.3% (all responders were also remitters, having ≥50% decrease in HAM-D scores and final scores ≤7). Anxiety improved with treatment (p = .012). GCS and HFRDIS scores decreased significantly. Among those who reported hot flashes at baseline, number and severity of hot flashes improved significantly overall (p = .009 and p = .008, respectively). Daytime but not nighttime hot flashes improved significantly.

Conclusions

These data support further study of duloxetine for the treatment of a spectrum of symptoms associated with the menopausal transition.     

Improving knowledge,attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: A randomized controlled trial

Objective

To test the effectiveness of an individualized educational intervention on knowledge, attitudes and beliefs about acute coronary syndrome (ACS).

Methods

This multi-site, randomized controlled trial was conducted on 1947 patients with a diagnosis of ACS. Both groups received usual in-hospital education. Participants randomized to the intervention group received a 40-min one to one individualized education session, delivered using motivational interviewing techniques. The intervention was reinforced 1 month and 6 months later. Knowledge, attitudes and beliefs were measured using the ACS Response Index. A total of 1136 patients (control, n = 551; intervention, n = 585) completed the questionnaire at baseline, 3 and 12 months. Data were analyzed using repeated measures analysis of variance. Ethical approval was obtained.

Results

There was a significant effect of the intervention on mean knowledge (p < 0.001), attitude (p = 0.003) and belief (p < 0.001) scores at 3 and 12 months.

Conclusion

Ensuring patients retain information post education has always been difficult to attain. This study demonstrated that patient education using motivational interviewing techniques and an individualized approach has the potential to alter knowledge, attitudes and beliefs about ACS among a high risk population.

Practice implications

This relatively short, simple and effective educational intervention could be delivered by nurses in multiple settings.     

Effects of a cognitive behavioral self-help program and a computerized structured writing intervention on depressed mood for HIV-infected people: A pilot randomized controlled trial

Objective

The aim of the present study was to examine whether low-resource, cost-effective intervention programs can be effective in improving depressed mood in people with HIV. The efficacy of a cognitive–behavioral self-help program (CBS) and a computerized structured writing intervention (SWI) were tested in a pilot randomized controlled trial.

Methods

Participants were members of a patient organization. They completed a pretest and posttest. The questionnaire included the HADS. Participants were randomly allocated to CBS (n = 24), SWI (n = 25) or a waiting list condition (WLC, n = 24). To evaluate changes in the continuous outcome measure, a 3 × 2 (group × time) repeated measures ANCOVA was performed. Also, an ANCOVA was performed using change scores.

Results

Respondents who followed the CBS improved significantly compared to the WLC. However, for people in the SWI condition no significant improvement on depression was found.

Conclusion

This pilot study suggests that a low-resource, cost-effective CBS program seems to be effective in reducing depressed mood in people living with HIV.

Practice implications

Because self-help programs can be delivered through regular mail or the internet, a high number of people could be reached while overcoming geographical and social barriers to treatment.     

Does health coaching change patients’ trust in their primary care provider?

Objective

To assess the impact of health coaching on patients’ in their primary care provider.

Methods

Randomized controlled trial comparing health coaching with usual care.

Participants

Low-income English or Spanish speaking patients age 18–75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia.

Main outcome measure

Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0–100 scale.

Analysis

Linear mixed modeling.

Results

A total of 441 patients were randomized to receive 12 months of health coaching (n = 224) vs. usual care (n = 217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p = 0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p = .03).

Conclusions

Health coaching appears to increase patients trust in their primary care providers.

Practice Implications

Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.